CMS Bundled Payment Models Address Cardiac Care, Hip Surgeries

CMS has introduced new bundled payment models for treating patients with cardiovascular problems and hip or femur fractures.

August 24, 2016 - The Centers for Medicare & Medicaid Services (CMS) have recently begun implementing additional alternative payment models centered on episodes of care. CMS has proposed new rules for managing the costs of care and coordination among Medicare fee-for-service beneficiaries. Essentially, bundled payment models would be used to reduce spending and improve the quality of care among several specific medical conditions.

Bundled payment models would be used to treat patients with acute myocardial infarctions as well as those undergoing coronary artery bypass grafts or treatment for surgical hip/femur fractures, according to a mailing from CMS. The federal agency is also making suggestions to update the Comprehensive Care for Joint Replacement (CJR) model, Which utilizes bundled payment models to cover the cost of care among Medicare beneficiaries receiving hip and knee replacement surgeries.

Last month, the Department of Health & Human Services announced the inclusion of bundled payment models in cardiac care As well as incorporating these reimbursement structures among other types of hip surgeries besides hip replacement, according to a press release from HHS. The proposal also includes using these payments structures within the rehabilitation services of cardiovascular disease.

It is expected that bundled payment models would further improve patient outcomes and care coordination between multiple medical facilities. The new models of payment are expected to reduce the costs associated with treating patients who have undergone a heart attack or are receiving bypass surgery. The reimbursement structures may also be implemented among patients receiving surgeries for hip and femur fractures that extend beyond that of hip replacements.

Incorporating the use of new bundled payment models would go a long way toward meeting the HHS goal of having 50 percent of Medicare payments in the form of alternative reimbursement structures.

“Having a heart attack or undergoing heart surgery is scary and stressful for patients and their families,” Health and Human Services Secretary Sylvia M. Burwell said in the release. “Today’s proposal is an important step to improving the quality of care Americans receive and driving down costs. By focusing on episodes of care and rewarding successful recoveries, bundled payments encourage hospitals to coordinate care to achieve the best outcomes possible for patients.”

The HHS release states that early results from bundled payment models have been promising, showing improved quality and more cost-effective delivery of care. The proposals from HHS also look to incentivize providers to increase the use of cardiac rehabilitation such as encouraging patients to work with dieticians, physical therapists, and cardiologists to improve their physical fitness and cardiovascular health.

“Patients want the peace of mind of knowing they will receive high-quality, coordinated care from the minute they’re admitted to the hospital through their recovery,” Patrick Conway, M.D., CMS Principal Deputy Administrator and Chief Medical Officer, said in a public statement. “The variation in cost and quality for the same surgery at different hospitals shows there are major opportunities for hospitals included in today’s models to reduce costs, improve care, and receive additional payments by improving patient outcomes.”

Healthcare providers who participate in these bundled payment models may also be eligible for financial incentives from the proposed Quality Payment Program, which is an important part of MACRA legislation.

“Today’s rule adds to the options for specialists who want to participate in Advanced Alternative Payment Models to a significant level,” Andy Slavitt, Acting Administrator of CMS, stated in the press release. “Expanding these options will help MACRA succeed in its goal of transforming the health care delivery system.”

The way bundled payment models work is by bringing more structure toward paying providers across a patient’s total experience throughout the healthcare continuum. The proposed payment structures from CMS will depend upon an episode of care - more specifically, for inpatient stays and the following 90 days after discharge, according to a CMS fact sheet.

The way the bundled payment proposal would work is by having CMS set prices for the several varying episodes of care based on historical cost data from the treatment of Medicare fee-for-service beneficiaries. Some adjustments would be made based on specific complexities of treating heart attacks or completing bypass surgery.

The reimbursement structures would also pay forward higher savings among those providers who improved the quality of care versus facilities that did not increase their performance levels. The type of quality metrics used would be mortality rates among patients with acute myocardial infarction, the number of days hospitalized or in acute care, and complication rates after hip and femur surgeries.

Bundled payment models incorporated by the CMS will have a clear goal of transitioning the healthcare industry - especially elderly care - from a fee-for-service payment structure to that of value-based care reimbursement, which rewards medical facilities for the quality of care produced instead of the quantity.